SAN FRANCISCO – A decade ago, California voters were the nation’s first to approve medical marijuana, and 10 other states have since followed suit. But the future of the landmark California statute is no clearer now than when voters headed to the polls Nov. 5, 1996.

The federal government still refuses to recognize Proposition 215, the Compassionate Use Act approved by 56 percent of voters. And U.S. authorities under both the Clinton and Bush administrations have won nearly every major legal battle over the measure.

“We refer to it as marijuana, not medical marijuana, regardless of its reported destination or use,” said Drug Enforcement Administration spokeswoman Casey McEnry, noting that marijuana is an illegal controlled substance under federal law.

The government’s war on drugs has also prompted a civil war of sorts within California: three of the state’s 58 counties, headed by San Diego County, claim in a lawsuit filed in state court that the measure is illegal.

A hearing is set for Nov. 16 in the lawsuit, which threatens to derail the state’s legal tolerance for the medicinal use of a drug that federal law places in the same category as heroin, cocaine and LSD.

A victory for those renegade counties might also set legal precedent undermining medical marijuana laws in other states with such laws – Alaska, Colorado, Hawaii, Maine, Montana, Nevada, Oregon, Rhode Island, Vermont and Washington. Voters in South Dakota will consider a medical marijuana measure Tuesday.

“The state cannot authorize somebody to do something that breaks federal law,” said Thomas Bunton, senior deputy counsel for San Diego County.

Medical marijuana is used by thousands of people suffering from AIDS, cancer, anorexia, chronic pain, arthritis, migraines and other illnesses, according to the Marijuana Policy Project. The nation’s medical marijuana laws generally allow those with a doctor’s recommendation to grow or possess small amounts of the drug.

In 1999, a branch of the National Academy of Sciences expressed concerns about the health risks of smoking marijuana, but acknowledged in a report that “there is no clear alternative for people suffering from chronic conditions that might be relieved by smoking marijuana, such as pain or AIDS wasting.”

Later research suggests it might reduce tumor proliferation and a study this year by the University of California at San Francisco showed marijuana “may offer significant benefit” to those suffering from hepatitis C.

The Food and Drug Administration does not recognize marijuana as having medical benefits.

California is the epicenter of the federal-state medical marijuana battle. Communities including Los Angeles, San Francisco, Oakland and West Hollywood have authorized storefront medical marijuana dispensaries

Proposition 215 does not expressly allow dispensaries, but Americans for Safe Access, a pro-marijuana lobbying group, estimates there are about 200 operating in California. For many backers of the law, it’s an imperfect way for patients to get pot.

“I thought we would have had more of a standardized distribution system by now,” said William Panser, an Oakland criminal defense lawyer who was among the handful of attorneys who crafted the proposition.

Federal agents have raided more than two dozen California dispensaries over the past decade, according to Americans for Safe Access. Some communities are now assisting in the crackdown, including San Diego, which recently shuttered 13.